What We Know - And What We Can Change - About Cesarean Birth in the U.S.

When three women in early labor walk into a hospital in the United States, we know that one of them will have her baby by cesarean section. Why is the surgical birth rate so high, and what can we do about it? We know that full term vaginal birth with mother and baby enjoying skin to skin during the first hour, with baby at the breast, and an environment filled with love and familiar voices is what both science and instinct tell us is best for mother, baby, and family. How do we make this a reality for more women in the U.S.? Identifying the issues can help us develop the best solutions through education and implementation of what we learn.

What are some of the challenges women face in achieving normal physiologic birth?

1. Hospital birth procedures. Time limits on stages of labor, interventive or interruptive hospital routines, and lack of support for women with challenging labors and longer labors may all contribute to high c-section rates. Experience shows us that:

Each woman's labor has its own rhythm that works well for her and her baby.

Even minor interventions, procedures, and interruptions can distract, slow down or even stop labor and can impact the progress.

Fetal heart monitors can restrict a woman's ability to move during labor and distract her and her team from the work at hand.

Continuity of care, even having one person such as a doula or midwife stay with a woman throughout her labor and birth can help her cope, decreasing the need for pain medication and increasing her confidence and ability to birth without intervention.

2. Inductions. The increasing rates of inductions may be a contributing factor in the high c-section rate.

Inductions with an unripe cervix or undescended fetal presenting part (the baby's head in a vertex presentation if well-flexed and low in the pelvis will work with the contractions to promote efficient labor and dilation of the cervix) may result in cesarean section.

The use of pitocin increases the need for pain medication, both of which may not be well tolerated by the baby and may lead to cesarean due to fetal distress - a classic snowball effect of one intervention leading to another. A new study also suggests that term newborns exposed to pitocin in labor have a higher rate of admission to Intensive Care than those who are not.

3. "Normal" pregnancy. Many "variations of normal" that used to be considered reasonable for vaginal delivery, such as breech and twins, are now candidates for routine cesarean section. Physicians may not have the training or skills to adequately assist due to inexperience in these types of vaginal births.

4. Restricted access to Vaginal Birth After Cesarean. Although we no longer believe "once a cesarean, always a cesarean," it has become harder and harder for women to find care providers to help them achieve a vaginal birth after cesarean. Although ACOG has modified its position on limiting VBACs to advanced care centers with 24 hour in-house operating room staff, liability insurance providers have been much slower to reinstate coverage to smaller hospitals who may have had excellent VBAC success rates 10 years ago but were forced to discontinue offering VBACs because of policy. Even large hospitals who have numerous providers in their on-call list may find it unrealistic to offer VBACs when all their providers are not on the same page. A woman may have to travel hours to find a provider and a hospital who will support her goal of normal physiologic birth after a previous C-section.

5. Birth culture. A cultural attitude that does not value normal labor and birth, does not believe in women's abilities to birth, and does not believe in pain as a positive force, does not foster a woman's confidence in herself, her body or her connection to her baby during labor and birth. Just recently, we saw a very public example of the devaluation of physiologic birth when a national sports commentator criticized a major league baseball player for missing the season's opening game in order to be at the birth of his child, and suggested the player and his wife should've opted for a scheduled a C-section.

Paving the Way for Change

We know that cesarean section, now considered "routine" surgery, has risks for both mother and baby, including infection, adhesions, anesthesia complications, unintended damage to mother's organs, unintended damage to baby, and respiratory compromise for baby. Repeated cesarean sections with subsequent pregnancies carry greater risks for mom with each surgical delivery. Also, delayed bonding and breastfeeding are often consequences of operating room and recovery room routines and incapacitation of mom.

Education and the implementation of our learnings are key to decreasing cesarean sections and making the benefits of normal physiologic birth available to more women and babies. Thankfully, more and more resources are available for women to get the information they need for the birth they want, including consumer organizations such as ICAN, Homebirth Cesarean International, and websites like MothersNaturally.org. For mothers who do have a cesarean delivery, they can minimize separation and delayed bonding by requesting support for skin-to-skin with baby in the operating room, breastfeeding with the help of a Certified Lactation Counselor (CLC) or International Board Certified Lactation Consultant (IBCLC) in the recovery room, and having a "mommy" surrogate (partner, family member, or friend) stay with baby for all necessary procedures and when mother is unavailable.

There are many ways we can work to make hospitals and surgical experiences more mommy, baby, and family friendly. Midwifery care in all settings, including birth centers and homebirth, is linked to lower C-section rates. Hospitals that achieve Baby Friendly certification focus on natural birth and breastfeeding. In May 2012, MANA, ACNM, and NACPM released a Joint Statement entitled Supporting Healthy Normal Physiologic Birth to provide guidance for the birth community in how we can change the culture of birth in the U.S. We are now encouraged by the recent Joint Statement for the Safe Prevention of the Primary Cesarean Delivery released last month by the American Congress of Obstetricians and Gynecologists and the Society of Maternal-Fetal Medicine as another impetus for finding solutions to the cesarean epidemic.

This month is Cesarean Awareness Month. We have been - and will continue to - highlight stories, images, and research about cesarean birth, prevention, and VBAC all month long on Facebook and Twitter. We hope you will join the conversation with us there, and add your comments here on the blog.

Author Jill Breen, CPM, CLC, has been serving women, babies and families for 36 years as a homebirth midwife and natural family health consultant in central Maine. She has 6 children and 8 grandchildren, all born into the hands of midwives including her own. She is working on Best Practices Guidelines with several state and national task forces. She served on the MANA Board, most recently as President, and is currently Communications Chair.

"When three women in early labor walk into a hospital in the United States, we know that one of them will have her baby by cesarean section."

That's not quite true, I'm afraid. Yes, the TOTAL cesarean rate in the US is one in three, however, that includes scheduled repeat cesareans, scheduled cesareans for complications such as placenta previa, malposition, or multiple pregnancy, or for emergencies that develop before labor begins, like HELLP.

Here's a better question. If a woman has had no major complications and walks into the hospital in spontaneous labor at full term with one head-down fetus, what is the probability that SHE will have a c-section?

If it's her first baby, 20%. If she's had previous births without any c-sections, it's about 3%.

So, an individual woman's risk of c-section depends on a lot of factors, many of which she already knows.

There are a number of contributing factors for the increasing rate of cesarean sections in the United States. However, by educating and empowering women on the physiological capabilities of their bodies during birth, utilizing midwives to support this physiological birthing process, and bringing complementary and alternative medicine (CAM) techniques into the delivery room; the rate of cesarean sections can begin to decline. Elective C-sections have become a more common option for some women who are unaware of the physiological changes that occur during the laboring process of childbirth and decide to forego the pain associated with childbirth. By choosing maternity care via a midwife, not only can a mother be educated on physiological birth, she can also be empowered to trust in the amazing capabilities of her body. Labor pains can also be reduced through the use of CAM in the delivery rooms to help relax and guide her through the contractions. I strongly believe that once these small steps are taken, we will begin to see a decline in the number of unnecessary cesarean sections performed in the US.

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